Mediclaim Insurance &
Hospitalisation Scheme
(11 Sep 2013 to 10 Sep 2014)
Entities Involved
Insurer :
Universal Sompo General Insurance Co. Ltd
Policy Period :
11 Sep 2013 to 10 Sep 2014
TPA :
Family Health Plan Ltd. ( FHPL)
Mediclaim pays for treating an ailment and
not for diagnosing an ailment
Sum Insured
PDPMIIITDM College has opted cover of
Sum Insured
Rs. 50,000/-
Policy Terms & Conditions
1). Pre-Existing:Covered.
2). 30 Days waiting: Applicable.
3). 1, 2 years Exclusions: 1 Year Exclusions are Applicable.
4). Co Payments: No Copayment.
5). Pre & Post Hospitalization: 30 / 60 Days.
6). Domiciliary Hospitalization Charges: Not Covered.
7). Dental & Spectacles & Hearing aids: Not Covered.
8). Health Check-up: Not Covered.
9). Special Conditions 1: Claim Submission for MRC should be
within 60 Days from the DOD from Hospital, Post 60 Days TPA should raise the deficiency
for the submission delay reason from the insured. Claim submission for Hospitals (PP
Claims) should be within 30 Days from DOD from Hospital, Post 30 Days TPA can reject
the claim with concurrence of USGI Claims Team.
10). Special Conditions 2:All other terms & conditions shall be as
per Standard GMP.
11). Room Notes: As per GMP conditions..
Definition of Hospital :
Any hospital which is tied up by FHPL and any Nursing home or hospital
which is Registered and has more than 15 Beds.
Definition of Hospitalization:
Minimum period of 24 hrs of admission in a hospital for a proper medical
management.
Time Limit Not Applicable For Specific Treatments Like
•
Dialysis
•
Chemotherapy
•
Eye surgery
What is not covered under this policy
Diseases
In-Patient Treatment
Others
Plastic Surgery (Cosmetic)
Laboratory Expenses not
consistent with treatment.
Spectacles,Contact Lens,
Hearing Aid
Orthodontics Treatment
Vitamins
Use of intoxicating drugs/ alcohol
Sterility/Venereal
Disease/Circumcision
Tonic inconsistent with
treatment.
Naturopathy
Intentional Self Injury
Telephone,Fax,Barber,Photoco
py, Vaccinations,Toiletries and
TV charges
Aids
Special diet and extra diet for
patients (unless prescribed by
the Doctor)
Congenital Diseases
External Implants
(External)
e.g. An operation to remove a
e.g. An operation to remove 6th finger, Skin Graphting
a 6th finger, Skin Graphting
Registration fees
What is not covered under this policy
Diseases
Convalescence /
General Debility.
In-Patient Treatment
Others
Supports and Accessories, e.g.
Crutches
Admission fees
Service,Maintenance and
Surcharges
Food & Beverages
Special Nursing, Attendant Pass
Telephone/Fax
Health Drinks:
e.g. Horlicks, Complan etc
Medical records/ Stationary
Xerox or Certifying charges
Abortion done for voluntary reasons
& before 12 weeks
Attendants Charges
Food and Beverage for Relatives
Special Nursing charges
Diagnostic Expenses (only for outpatient)
Extra Bed/ Bed retaining
charges
Damage done by the patient
(accidentally). Damage charges not
covered.
TV/ Laundry
Do’s
1. Carry your ID card (IDEA)/ E Card (FHPL) at the time of admission at
network hospitals
2. Incase of emergency admission kindly contact FHPL within 24 hrs of
Hospitalisation
3. Incase of emergency kindly refer your companies name and your Emp
No at the time of admission
4. Take a pre approval from FHPL for all the elective cases
5. Sign on the final bill at the time of discharge from the hospital
6. For any other assistance call the account manager
How to avail benefits under your policy

Member
approaches
with Network
Hospitals with
ID
Hospital sends
Intimation to
FHPL
Member approaches
Any other Hospital
Eligibility
Avails treatment, makes
upfront payment
Submits bills to FHPL for
reimbursement
TAT : less than 2 hr for routine cases
Emergency : No authorization required
Regularization within 24 Hrs
Not
Covered
Out of Pocket
payment
Covered
Authorization as
per eligibility
Cashless treatment
at NWH
Documents required for reimbursement
1.
Original detailed discharge summary
2.
Original investigation reports along with bill
3.
Original Hospital Bill-consolidated and with detail breakup of every
component of the bill with the patients signature on it.
4.
Incase of surgical packages – detail breakup of the package
5.
Medicine bills with prescriptions.
6.
Claim Form – ( available on FHPL website )
7.
MLC Certificate from the hospital in the case of Road traffic accident.
Or a certificate from the treating doctor mentioning that the patient was
not under the influence of alcohol at the time of Accident.
8.
Payment receipt for the payment done to the hospital.
*30 Days pre & 60 Days Post hospitalization
Original investigation reports along with bills & receipts
1.
Consultation receipts.
2.
Medicine bills with prescriptions
Our commitment to serve You …….
……. Is absolute